Case and Research Letters
Disseminated Pediatric Herpes Zoster
Herpes zóster diseminado infantil
A. Ortiz-Brugués
, X. Soria-Gili, J.M. Casanova-Seuma
Corresponding author
Servicio de Dermatología, Hospital Universitari Arnau de Vilanova, Lleida, Spain
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Ortiz-Brugués, X. Soria-Gili, J.M. Casanova-Seuma" "autores" => array:3 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Ortiz-Brugués" "email" => array:1 [ 0 => "ariadna.ortiz.brugues@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "X." "apellidos" => "Soria-Gili" ] 2 => array:2 [ "nombre" => "J.M." "apellidos" => "Casanova-Seuma" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Dermatología, Hospital Universitari Arnau de Vilanova, Lleida, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "*" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Herpes zóster diseminado infantil" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1367 "Ancho" => 900 "Tamanyo" => 147697 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In this image, we can better observe the degree of lesion dissemination, affecting the face, neck, torso, and limbs.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Herpes zoster (shingles) is rare in children with no history of chickenpox but can occur when their mothers are infected with the virus during pregnancy. In such cases, herpes zoster generally presents after the first year of life after maternal immunoglobulin (Ig) G antibodies have disappeared from the child's blood. Disseminated pediatric herpes zoster is an unusual condition.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 2-year-old child who was treated at the emergency department of our hospital in July 2011 with an acute and painful rash distributed metamerically in the left thoracic region. The patient was diagnosed with herpes zoster and treated with hot dry compresses. The medical history showed that the mother had contracted chickenpox at pregnancy week 21. In all other respects, the patient was a healthy child who was not taking any medications. She had an up-to-date vaccination schedule, but had not been vaccinated against the varicella zoster virus. Five days later, the patient was brought back to the emergency department because the rash had spread and there was associated pain, fever, and anorexia.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Examination of the skin revealed a rash consisting of clustered vesicles (some containing blood) on an erythematous base, distributed metamerically following dermatomes T4 and T5 (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). We also observed a generalized rash made up of hundreds of isolated vesicles all over the body (<a class="elsevierStyleCrossRefs" href="#fig0010">Figs. 2 and 3</a>). No palpable lymph nodes were detected.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The child was hospitalized with a diagnosis of disseminated pediatric herpes zoster and treated with intravenous acyclovir at a dosage of 10<span class="elsevierStyleHsp" style=""></span>mg/kg every 8<span class="elsevierStyleHsp" style=""></span>hours for 5 days. She also received intravenous analgesia, and the rash was treated with topical potassium permanganate. Laboratory test results revealed mild iron deficiency (15 mcg/dL), no anemia, and high titers of IgG herpes zoster antibodies. The results of other immune studies, including serology for cytomegalovirus and human immunodeficiency virus (HIV) were normal or negative. No signs or symptoms of visceral involvement were detected. After 5 days of treatment, the patient's symptoms improved and she was discharged; oral iron supplementation was prescribed.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The impact on the fetus of maternal varicella infection during pregnancy depends on when the infection occurs.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> If the mother is infected before week 20, there is a high risk of miscarriage, although in some cases such infection can lead to congenital varicella syndrome. The clinical effects of congenital varicella syndrome are usually severe and include pitted and pigmented dermatomal skin scarring, cataracts, chorioretinitis, Horner syndrome, limb hypoplasia, cortical atrophy, seizures, and mental retardation.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">If maternal infection occurs between weeks 21 and 28, in most cases the child will not have symptoms at birth because the infection will be controlled by maternal IgG antibodies.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The child may develop herpes zoster later in life once these antibodies disappear (which occurs after 1 or 2 years); this was the case in our patient.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,3</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">If maternal infection is perinatal (within 5 days prior to delivery), there is a high risk of neonatal chickenpox, which may progress mildly if it presents with skin involvement alone. However, complications are more common at this age due to the poorly developed immune system of the neonate and may include pneumonia, hepatitis, and meningoencephalitis. The risk of neonatal chickenpox increases in premature and post-term infants and in cases of perinatal infection because in these conditions the child receives less protection from the maternal IgG antibodies and their own production of IgG antibodies is low.</p><p id="par0040" class="elsevierStylePara elsevierViewall">As with adult herpes zoster, pediatric herpes zoster is caused by reactivation of latent varicella-zoster virus in nerve ganglia. Disseminated pediatric herpes zoster is a rare condition and, as with the adult form, it is more often found in immunosuppressed patients (HIV, lymphomas, immunosuppressant therapy), who tend to have visceral involvement.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It is therefore important to rule out underlying immunosuppression and visceral involvement in patients with disseminated forms of the disease. In cases with only skin involvement, the prognosis is good and treatment with oral acyclovir is recommended at a dosage of 20 to 30<span class="elsevierStyleHsp" style=""></span>mg/kg/d, divided into 5 doses, each administered at 4-hour intervals, with a maximum dosage of 800<span class="elsevierStyleHsp" style=""></span>mg/d for 7 days. Higher dosages are only used in cases of visceral involvement. For cases involving acyclovir resistance, the treatment of choice is intravenous foscarnet.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In summary, we present the case of a 2-year-old immunocompetent patient who developed disseminated pediatric herpes zoster; the only medical history of interest was maternal varicella infection during pregnancy. Disseminated pediatric herpes zoster is a rare condition that usually affects immunosuppressed individuals and is generally associated with visceral involvement.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Nevertheless, 5 other cases of patients with disseminated disease confined to the skin have been published<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1,5,6</span></a>; 2 of the patients also presented iron deficiency with no anemia.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> However, no association between iron deficiency and pediatric herpes zoster has yet been established.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Ortiz-Brugués A, et al. Herpes zóster diseminado infantil. Actas Dermosifiliogr. 2013;104:441-2.</p>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1371 "Ancho" => 900 "Tamanyo" => 194461 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Front of the chest showing clustered vesicles (some containing blood) on an erythematous base.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1368 "Ancho" => 900 "Tamanyo" => 174278 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The back shows involvement in T4 and T5, as well as widespread exanthema formed by hundreds of isolated and dispersed vesicles.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 1367 "Ancho" => 900 "Tamanyo" => 147697 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">In this image, we can better observe the degree of lesion dissemination, affecting the face, neck, torso, and limbs.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Two cases of disseminated cutaneous herpes zoster in infants after intrauterine exposure to varicella-zoster virus" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C.P. 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| 2024 August | 181 | 119 | 300 |
| 2024 July | 181 | 109 | 290 |
| 2024 June | 180 | 111 | 291 |
| 2024 May | 147 | 110 | 257 |
| 2024 April | 152 | 60 | 212 |
| 2024 March | 175 | 39 | 214 |
| 2024 February | 199 | 45 | 244 |
| 2024 January | 192 | 49 | 241 |
| 2023 December | 229 | 36 | 265 |
| 2023 November | 195 | 68 | 263 |
| 2023 October | 209 | 55 | 264 |
| 2023 September | 232 | 56 | 288 |
| 2023 August | 190 | 39 | 229 |
| 2023 July | 174 | 60 | 234 |
| 2023 June | 138 | 44 | 182 |
| 2023 May | 141 | 45 | 186 |
| 2023 April | 162 | 46 | 208 |
| 2023 March | 144 | 34 | 178 |
| 2023 February | 128 | 40 | 168 |
| 2023 January | 125 | 34 | 159 |
| 2022 December | 121 | 54 | 175 |
| 2022 November | 105 | 54 | 159 |
| 2022 October | 82 | 46 | 128 |
| 2022 September | 54 | 45 | 99 |
| 2022 August | 73 | 42 | 115 |
| 2022 July | 92 | 34 | 126 |
| 2022 June | 119 | 16 | 135 |
| 2022 May | 230 | 52 | 282 |
| 2022 April | 205 | 47 | 252 |
| 2022 March | 207 | 41 | 248 |
| 2022 February | 223 | 39 | 262 |
| 2022 January | 218 | 35 | 253 |
| 2021 December | 165 | 49 | 214 |
| 2021 November | 153 | 53 | 206 |
| 2021 October | 202 | 58 | 260 |
| 2021 September | 147 | 50 | 197 |
| 2021 August | 177 | 45 | 222 |
| 2021 July | 140 | 33 | 173 |
| 2021 June | 160 | 37 | 197 |
| 2021 May | 133 | 35 | 168 |
| 2021 April | 232 | 57 | 289 |
| 2021 March | 141 | 27 | 168 |
| 2021 February | 100 | 44 | 144 |
| 2021 January | 79 | 22 | 101 |
| 2020 December | 43 | 20 | 63 |
| 2020 November | 35 | 25 | 60 |
| 2020 October | 46 | 8 | 54 |
| 2020 September | 43 | 10 | 53 |
| 2020 August | 39 | 37 | 76 |
| 2020 July | 23 | 15 | 38 |
| 2020 June | 40 | 27 | 67 |
| 2020 May | 21 | 23 | 44 |
| 2020 April | 25 | 26 | 51 |
| 2020 March | 33 | 18 | 51 |
| 2020 February | 3 | 4 | 7 |
| 2020 January | 0 | 19 | 19 |
| 2019 December | 4 | 8 | 12 |
| 2019 November | 0 | 2 | 2 |
| 2019 October | 0 | 9 | 9 |
| 2019 September | 4 | 5 | 9 |
| 2019 August | 0 | 6 | 6 |
| 2019 July | 0 | 22 | 22 |
| 2019 June | 0 | 26 | 26 |
| 2019 May | 5 | 73 | 78 |
| 2019 April | 0 | 31 | 31 |
| 2019 March | 2 | 15 | 17 |
| 2019 February | 4 | 17 | 21 |
| 2019 January | 3 | 6 | 9 |
| 2018 December | 4 | 6 | 10 |
| 2018 November | 3 | 3 | 6 |
| 2018 October | 3 | 0 | 3 |
| 2018 September | 3 | 4 | 7 |
| 2018 August | 0 | 13 | 13 |
| 2018 July | 0 | 10 | 10 |
| 2018 June | 0 | 8 | 8 |
| 2018 May | 0 | 13 | 13 |
| 2018 April | 0 | 6 | 6 |
| 2018 March | 1 | 6 | 7 |
| 2018 February | 34 | 11 | 45 |
| 2018 January | 55 | 7 | 62 |
| 2017 December | 52 | 11 | 63 |
| 2017 November | 40 | 12 | 52 |
| 2017 October | 44 | 24 | 68 |
| 2017 September | 39 | 10 | 49 |
| 2017 August | 39 | 17 | 56 |
| 2017 July | 48 | 17 | 65 |
| 2017 June | 33 | 26 | 59 |
| 2017 May | 32 | 19 | 51 |
| 2017 April | 35 | 9 | 44 |
| 2017 March | 37 | 29 | 66 |
| 2017 February | 36 | 28 | 64 |
| 2017 January | 25 | 16 | 41 |
| 2016 December | 47 | 13 | 60 |
| 2016 November | 68 | 20 | 88 |
| 2016 October | 72 | 16 | 88 |
| 2016 September | 102 | 14 | 116 |
| 2016 August | 68 | 19 | 87 |
| 2016 July | 49 | 14 | 63 |
| 2016 June | 11 | 14 | 25 |
| 2016 May | 5 | 7 | 12 |
| 2016 April | 4 | 1 | 5 |
| 2016 March | 4 | 15 | 19 |
| 2016 February | 1 | 12 | 13 |
| 2016 January | 8 | 1 | 9 |
| 2015 December | 8 | 10 | 18 |
| 2015 November | 11 | 17 | 28 |
| 2015 October | 8 | 1 | 9 |
| 2015 September | 12 | 8 | 20 |
| 2015 August | 13 | 3 | 16 |
| 2015 July | 60 | 11 | 71 |
| 2015 June | 45 | 12 | 57 |
| 2015 May | 36 | 3 | 39 |
| 2015 April | 36 | 4 | 40 |
| 2015 March | 33 | 5 | 38 |
| 2015 February | 23 | 2 | 25 |
| 2015 January | 21 | 4 | 25 |
| 2014 December | 19 | 8 | 27 |
| 2014 November | 23 | 6 | 29 |
| 2014 October | 28 | 6 | 34 |
| 2014 September | 14 | 4 | 18 |
| 2014 August | 26 | 6 | 32 |
| 2014 July | 14 | 6 | 20 |
| 2014 June | 32 | 12 | 44 |
| 2014 May | 31 | 9 | 40 |
| 2014 April | 29 | 8 | 37 |
| 2014 March | 27 | 8 | 35 |
| 2014 February | 31 | 6 | 37 |
| 2014 January | 41 | 10 | 51 |
| 2013 December | 28 | 5 | 33 |
| 2013 November | 11 | 3 | 14 |
| 2013 October | 15 | 3 | 18 |
| 2013 September | 10 | 5 | 15 |
| 2013 August | 8 | 9 | 17 |
| 2013 July | 10 | 9 | 19 |
| 2013 June | 3 | 4 | 7 |
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